Claim Denials for Medically Unnecessary Ambulance Transports

NGS has seen a consistent number of claim denials for reason code 55B10. Denial reason code 55B10 indicates that your claim was denied after review and it was determined that the beneficiary could have been safely transported by another means (i.e., Ambulette, private car). Within this article, you will find the information needed to assist your facility in avoiding claim denials for reason code 55B10.

Medical Necessity and Coverage Guidelines for Ambulance Transport

Medical necessity is established when the patient's condition is such that the use of any other method of transportation is contraindicated. When some means of transportation other than an ambulance could be used without endangering the individual's health, and when such other transportation is not actually available, no payment may be made for ambulance services.

It is important to note that the presence (or absence) of a physicians order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary. The ambulance service must meet all program coverage criteria in order for payment to be made.

Payment may be made for expenses incurred by a patient for ambulance service when the following conditions have been met:

The patient was transported by an approved supplier of ambulance services.

The patient was suffering from an illness or injury, which contraindicated transportation by other means.

NGS presumes the medical necessity requirement was met if the submitted documentation indicates that the patient:

Was transported in an emergency situation

Needed to be restrained to prevent injury to the beneficiary or others

Exhibits signs and symptoms that indicate the possibility of acute stroke

Had to remain immobile because of a fracture that had not been set

Was experiencing severe hemorrhage

Could be moved only by stretcher

Was bed-confined before and after the ambulance trip

A beneficiary is bed-confined if he/she is:

Unable to get up from bed without assistance

Unable to ambulate

Unable to sit in a chair or wheelchair

In the absence of any of the conditions listed above, additional documentation should be obtained to establish medical need where the evidence indicates the existence of the circumstances listed below:

Patients condition would not ordinarily require movement by stretcher

The individual was not admitted as a hospital inpatient (except in accident cases)

The ambulance was used solely because other means of transportation were unavailable

The individual merely needed assistance in getting from his room or home to a vehicle

Avoiding Reason Code 55B10

Reason code 55B10 can be avoided by ensuring that the ambulance transport meets the medical necessity guidelines as described above. Develop or update any internal policies/procedures that will help your facility to be in compliance with submitting proper claims to Medicare. Medicare does not make payment when the ambulance transport is not medically necessary.

Most recurring reason codes can and should be avoided. We encourage all providers to view the Top Claims Submission Errors listing in our website under the Claims and Appeals tab. We also provide information on how the top reason codes can be prevented. Preventing recurring reason codes is very important as it can save on staff time, prevent unnecessary claim denials and help increase your facilities Medicare cash flow!